Aanesthetic Agents for Day Surgery - NIHR Health Technology ...

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16 Literature review TABLE 4 Comparisons under study in the paediatric review Comparison No. of studies Studies Propofol vs thiopentone induction 3 Cheng et al., 1998; 139 Hannallah et al., 1994; 146 into savings in resource use. Hannallah and co-workers 146 found no reduction in length of stay with propofol. Inhalational versus intravenous induction Four studies examined inhalational versus intravenous induction. 144,146,148,161 Kotiniemi and Ryhanen 148 reported a reduction in PONV before and after discharge for halothane over thiopentone. Viitanen and co-workers 161 did not find any differences in PONV before or after discharge or length of stay for propofol and sevoflurane. Hannallah and co-workers 146 reported a reduction in PONV before discharge for propofol versus halothane, but also reported a reduction in PONV after discharge in children induced and maintained with halothane versus propofol. Gurkan and co-workers 144 measured only emesis and the number of occurrences of the oculocardiac reflex during strabismus surgery. They found less vomiting with propofol. Sevoflurane versus halothane induction Nine studies examined the use of sevoflurane versus the use of halothane for induction and maintenance. 13,143,147,149,151,153,155,164,166 Runcie et al., 1993 157 Propofol vs sevoflurane induction 2 Gurkan et al., 1999; 144 Viitanen et al., 1999 161 Halothane vs thiopentone induction 1 Kotiniemi and Ryhanen, 1996 148 Propofol vs halothane induction 4 Crawford et al., 1998; 140 Hannallah et al., 1994; 146 Ved et al., 1996; 160 Watcha et al., 1991 163 Sevoflurane vs halothane induction + maintenance 11 Sury et al., 1996; 13 Ariffin et al., 1997; 138 Greenspun et al., 1995; 143 Johannesson et al., 1995; 147 Lermasn et al., 1996; 149 Meretoja et al., 1996; 151 Naito et al., 1991; 153 Piat et al., 1994; 155 Vitanen et al., 2000; 162 Walker et al., 1997; 164 Welborn et al., 1996 166 Propofol vs isoflurane maintenance 3 Davis et al., 1997; 141 Hamunen et al., 1997; 145 Martin et al., 1993 150 Halothane vs desflurane maintenance 2 Davis et al., 1994; 142 Welborn et al., 1996 166 Propofol vs halothane maintenance 4 Moore and Underwood, 1994; 152 Reimer et al., 1993; 156 Ved et al., 1996; 160 Weir et al., 1993 165 Halothane ± nitrous oxide 4 Pandit et al., 1995; 154 Splinter et al., 1995; 158 Crawford et al., 1998; 140 Watcha et al., 1999 163 Propofol vs sevoflurane maintenance 2 Gurkan et al., 1999; 144 Uezono et al., 2000 159 Sevoflurane vs halothane maintenance 2 Ariffin et al., 1997; 138 Viitanen et al., 2000 162 Intravenous versus inhalational maintenance Three studies compared isoflurane with propofol. 141,145,150 Davis and co-workers 141 and Hamunen and co-workers 145 reported no reduction in PONV before discharge. Martin and co-workers 150 measured PONV before and after discharge and reported a reduction in both parameters. Martin and co-workers 150 and Davis and co-workers 141 reported no change in length of stay with the two regimens. Four studies compared propofol with halothane. 152,156,160,165 Reimer and co-workers 156 reported that, in a study of strabismus patients, the use of propofol with or without the use of N 2O decreased only early emesis when compared with thiopentone or halothane; the overall rate of PONV was not reduced. All studies reported no reduction in PONV before discharge. Moore and Underwood 152 measured the rate of PONV after discharge, and reported no reduction. No studies reported a difference in length of stay. Ved and co-workers 160 found less vomiting with propofol, but no difference in discharge times or admission rates. Weir and co-workers 165 measured only emesis, and found less with propofol.
Different inhalational agents for maintenance Sevoflurane versus halothane Eleven studies compared sevoflurane with halothane. 13,138,143,147,149,151,153,155,162,164,166 Only Piat and co-workers 155 did not record PONV before discharge, and only Meretoja and coworkers 151 reported a reduction in PONV before discharge with sevoflurane. Walker and coworkers, 164 Welborn and co-workers 166 and Naito and co-workers 153 recorded the rate of PONV after discharge, and did not find a difference between the two agents. Only Piat and coworkers, 155 Naito and co-workers 153 and Walker and co-workers 164 did not record the length of stay before discharge, and only Meretoja and co-workers 151 reported a reduction, with sevoflurane. Johannesson and co-workers, 147 Lerman and co-workers 149 and Sury and coworkers 13 reported increased emergence agitation with sevoflurane over halothane. Viitanen and co-workers 162 and Ariffin and co-workers 138 found less vomiting and a more rapid emergence with sevoflurane. Desflurane versus halothane Two studies compared desflurane with halothane. 141,166 Neither study reported differences in PONV or length of stay with the two agents. Inhalational versus intravenous agents for maintenance Propofol versus sevoflurane Two studies compared propofol maintenance with sevoflurane maintenance. 144,159 Uezono and co-workers 159 found a more rapid emergence and a greater incidence of emergence delirium with sevoflurane. Despite a greater time spent in the postanaesthetic care unit, the patient satisfaction scores for propofol were higher. Gurkan and co-workers 144 only measured emesis and the number of occurrences of the oculocardiac reflex (surgical reflexes resulting in adverse haemodynamic changes), and found less vomiting but more occurrences of the oculocardiac reflex with propofol. The role of N 2O Twenty-three of the 28 studies used N 2O in all alternatives. Only Cheng and co-workers, 139 Moore and Underwood, 152 Uezono and coworkers 159 and Splinter and co-workers 158 used anaesthetic techniques in the absence of N 2O. Four studies 140,154,158,163 were found that addressed the impact of N 2O. Splinter and co-workers 158 reported that N 2O did not increase the incidence of vomiting in children undergoing myringotomy, although vomiting increased with age and was © Queen’s Printer and Controller of HMSO 2002. All rights reserved. Health Technology Assessment 2002; Vol. 6: No. 30 associated with an increase in length of stay. Pandit and co-workers 154 measured only the length of stay on the postanaesthetic care unit and vomiting, and found no effect of N 2O on either. Crawford and co-workers 140 reported that N 2O had little effect on the rate of recovery after propofol, but it significantly increased the incidence of PONV. Watcha and co-workers 163 concluded that TIVA with propofol resulted in a more rapid recovery and less PONV than a halothane–nitrous oxide–droperidol regimen. Impact of age Some studies reported an increase in PONV with age. 158 Any study examining the impact of anaesthesia on PONV in children will have to take this into account. Relevance of the clinical evidence to UK practice Only four studies were from the UK, so different practice patterns in the studies may reduce their relevance to UK practice. However, most studies were grade I RCTs and all were published in the last 10 years, so this may reduce confounders and improve relevance. Desflurane is not used commonly in the UK, but all the other agents are used. Some studies were carried out on strabismus surgery or tonsillectomies, which pose an increased risk of surgically induced complications. Current issues and uncertainties This review highlights the following issues and uncertainties: • The evidence available is primarily from small RCTs concentrating on discharge times and PONV before discharge, with insufficient emphasis on clinical parameters after discharge. • It is not clear from the evidence which is the optimal agent for induction or maintenance. • It is not clear whether the use of propofol, rather than inhalational agents, for induction reduces PONV. • There appears to be no difference in clinical parameters between sevoflurane and halothane, apart from emergence agitation. • It is not clear that N 2O has any impact on clinical parameters. • TIVA is not yet standard practice in day-case paediatric anaesthesia. • The number of drugs available means that most studies cannot be directly compared because they used different combinations of drugs, or because they used the same drugs but given in different ways. 17
Page 1 and 2: Which anaesthetic agents are costef
Page 3: Which anaesthetic agents are costef
Page 6 and 7: NHS R&D HTA Programme The NHS R&D H
Page 8 and 9: Contents Appendix 6 Adult patient-b
Page 11 and 12: Background The aim of the project w
Page 13: • The incidence of PONV was low d
Page 16 and 17: 2 Introduction dizziness or disorie
Page 18 and 19: 4 Introduction a reduced incidence
Page 20 and 21: 6 Introduction willingness to pay f
Page 22 and 23: 8 Literature review included in the
Page 24 and 25: 10 Literature review TABLE 1 Compar
Page 26 and 27: 12 Literature review intermediate a
Page 28 and 29: 14 Literature review TABLE 3 Compar
Page 32 and 33: 18 Literature review Patient-based
Page 34 and 35: 20 Literature review TABLE 5 contd
Page 36 and 37: 22 Literature review No studies fol
Page 38 and 39: 24 Literature review (30%) and meth
Page 40 and 41: 26 Literature review • There are
Page 42 and 43: 28 National survey of anaesthetic p
Page 50 and 51: 36 Economic evaluation methods (inc
Page 52 and 53: 38 Economic evaluation methods The
Page 54 and 55: 40 Economic evaluation methods Tabl
Page 56 and 57: 42 Economic evaluation methods simi
Page 58 and 59: 44 Economic evaluation methods Prob
Page 61 and 62: Recruitment to the CESA RCT The stu
Page 63 and 64: Clinical outcome data PONV by anaes
Page 65 and 66: The findings from the logistic regr
Page 67 and 68: TABLE 29 The length of stay and pri
Page 69 and 70: 140 120 100 80 60 40 20 0 No. of pa
Page 71 and 72: 250 200 150 100 50 0 No. of patient
Page 73 and 74: TABLE 37 Deterministic sensitivity
Page 75 and 76: 20 15 10 5 0 -5 Difference in varia
Page 77 and 78: Patient admitted for day surgery an
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Recruitment to the CESA RCT The stu
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TABLE 49 The occurrence of any PONV
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60 50 40 30 20 10 0 No. of patients
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a scale effect for scenario A, but
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The mean CVs for avoidance of PONV
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1.80 The new variable cost and tota
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100 90 80 70 60 50 40 30 20 10 0 Su
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The structure and content of this d
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nurses to have an in-depth knowledg
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agent used (see appendix 18). It wa
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Furthermore, anaesthetists operate
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The CESA project was designed to as
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practice, such as the use of midazo
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1. Royal College of Surgeons of Eng
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60. Cheng KI, Chu KS, Fang YR, Su K
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112. Raeder J, Gupta A, Pedersen FM
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162. Viitanen H, Baer G, Annila P.
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220. Rosenberg KM, Bridge P, Brown
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The range of databases interrogated
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24. preferen$.mp. [mp=title, abstra
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110 Appendix 2 TABLE 65 contd Summa
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112 Appendix 3 Quality assessment o
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TABLE 69 Summary of paediatric pati
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TABLE 69 contd Summary of paediatri
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TABLE 70 Characteristics of cost or
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TABLE 71 Quality of cost or economi
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TABLE 71 contd Quality of cost or e
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Abbott J, Abbott P. Psychological a
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Hall JE, Stewart JIM, Harmer M. Sin
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Struys M, Versichelen L, Thas O, He
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182 Appendix 11
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184 Appendix 11
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186 Appendix 11
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188 Appendix 11
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The aim of this study was to develo
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anaesthetics in day surgery, using
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© Queen’s Printer and Controller
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Background The empirical study quan
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Satisfaction with care Nearly all (
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TABLE 76 Reason given for preferenc
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TABLE 79 Comparisons with previous
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TABLE 80 Reason given for preferenc
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TABLE 81 Reason given for willingne
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Background Variable costs account f
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TABLE 85 Unit costs for the purchas
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Background The empirical study requ
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Ethical approval This was covered b
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20 15 10 5 0 -5 -10 -15 True weight
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15 10 5 0 -5 -10 True weight - Dion
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224 Appendix 19 • patients aged o
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All staff unit costs were for the y
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Background Fixed costs account for
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232 Appendix 22 March, Tuesday 15 A
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234 Appendix 23 TABLE 96 Reasons fo
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Patients were coded using the OPCS
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Q03.4 punch biopsy of cervix Q03.5
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This section displays the associati
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given in Table 103 confirm the age
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TABLE 107 Occurrence of PONV by dur
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248 Appendix 27 TABLE 113 Frequency
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This section displays the associati
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The adverse events observed in the
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262 Health Technology Assessment Pr
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264 Health Technology Assessment Pr
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